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Joaquin County-Environmental Health Depart 600 k_ivlain Street-Stockton CA 95202-Phone: 209-40.-3'420 RAYMENT RECEIVED f D4Y- APPLICATION JAN 13 2011 ` ENVIRONMENTAL HEALTH fl 1 3 I SAE JOAQU!NROhw COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMEW. ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0011914 *Additional Employees State ID#: 39000370 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000370 Site Name: A SAMBADO&SON 39-370 Location: 15294 E EIGHT MILE RD, LINDEN Operator: A SAMBADO&SON INC Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 Legal Owner: SAMBADO, LAWRENCE J&BEVERLY New Owner? ❑Yes ❑ No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets FA M=LY Number of Showers Number of Lavatories Women: Number of Toilets 1-IOC15 INr Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancv Dates: Buildings Employees Dormitories from MARCH to GCTO BE R Crop SF Dwellings from / / to /_/ Crop Apartments Owner Owned&LI RV Total Number of Days to be used this Calendar Year: &SO Owner Owned RR Cars Total Days Occupied by 25 or more Employees: NON E MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule Permanent Camp Annual Permit Fet $35.00+ Number of Employees 10 @$12.00 each=$ QiO ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee S70.00+ Number of Employees a,$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE S 155.00 Remit TOTAL FEE as CALCULATED A13OVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING.ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Corte and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name LAWRENCE (2AMBADt7 Title PRESMbrNT E] Partnership (Please PRINT or TYPE) A Corporation Address MrM N, _ rU,( L L zN QE C q 5 QBtp Phone aOq_ q 3 I—a5(p p Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Reeeipt# Received By Account ID s ` \1 \ \ ✓ J C \I l`, 0023136 Facility ID Program Record ID PIE Assigned to PWS ID FA0013764 PR0518217 2765 2424-VELOSO-CACAPIT WA0515716 Report#:7066.rot ��(� Z�a2�� Application Printed:11/2/2010